HOOKAH POLICY OVERVIEW: OPTIONS FOR LOCAL GOVERNMENTS - Public Health Law Center
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HOOKAH POLICY OVERVIEW: OPTIONS FOR LOCAL GOVERNMENTS
WHO WE ARE
Law and Policy Partnership to End the Commercial Tobacco Epidemic
The Law and Policy Partnership to End the Commercial Tobacco Epidemic (the
Partnership) is a joint initiative of the American Lung Association and the Public Health
Law Center to support tobacco control professionals in their work to end the commercial
tobacco epidemic in California.
The Partnership provides free technical assistance, research, training, and analysis to
help communities pass strong local tobacco ordinances that are both effective and
legally sound.
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Image credit: Sam Bradd https://drawingchange.com/gathering-wisdom-visuals-for-a-healthy-future/
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BACKGROUND: WHAT IS A HOOKAH?
• Also known as shisha, waterpipe, narghile,
and other terms
• Hookahs range in size from very small to
multi-hosed and very large
• Generally comprised of:
– glass base filled with water
– Loose-leaf tobacco wrapped in perforated
aluminum foil and placed directly
underneath lit charcoal
– tray to catch coals
– hose with a mouthpiece for smoking
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BACKGROUND: HOOKAH AND FLAVORS
• Hookah tobacco, or shisha, traditionally
comprised of honey, molasses, dried fruits,
and tobacco
• Today’s shisha comes in a vast array of
flavors, including gummi bear, hipster mint,
lemon muffin, peppermint shake, and mint
chocolate
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FLAVORED HOOKAH ATTRACTS YOUTH
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Credit: Truth Initiative 2018
FLAVORED HOOKAH ATTRACTS YOUTH
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Credit: Truth Initiative 20181/15/2021 11
MYTH: HOOKAH IS SAFER THAN CIGARETTES
• Recent 2020 study showed that among 18-24
year-olds, hookah was perceived as a less
toxic form of tobacco consumption
• 2011 study of high school students in San
Diego found that 46.3 percent of students
thought hookah was safer or less addictive
than cigarettes
• Perception that the water “filters” the toxins in
the smoke, making it healthier than cigarettes
1/15/2021 12
Image credit: Hookah smoking (Source: Pixabay)
https://www.verywellmind.com/am-i-too-old-to-quit-smoking-2825355TRUTH: HOOKAH CAN BE WORSE THAN CIGARETTES
• One hookah smoking session can equal up to
smoking 100 cigarettes (or 5 cigarette packs)
• Hookah smoker exposed to 150 times more
smoke than the average cigarette smoker and
1.7 times the nicotine
• Hookah smoke exposes user to 8.4 times the
carbon monoxide, along with heavy metals,
carcinogens, and volatile organic compounds
from the burning coals
• Hookah smoker exposed to 36 times the tar
of a cigarette
1/15/2021 13TRUTH: HOOKAH HAS SIGNIFICANT HEALTH IMPACTS
• Other long and short-term health impacts include:
• Lung disease/respiratory illness
• Oral, lung, bladder, gastric, and other cancers
• Cardiovascular disease
• Infectious disease (including COVID-19 and other viruses)
• Nicotine addiction
• Secondhand smoke exposure
• Carbon monoxide poisoning
1/15/2021 14
Photo Credit: https://www.medicalnewstoday.com/articles/322982MYTH: HOOKAH LOUNGES CATER TO AN ETHNIC MINORITY
• Many of the arguments raised by the hookah
industry argue that hookah is a “cultural”
practice unique to Middle-Eastern, Egyptian,
Indian, and other cultures and should be
respected and treated differently
• Hookah bars often have exotic names and
décor
• Implication that failure to exempt hookah from
flavor bans targets an ethnic minority
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Photo Credit: Las Vegas SunTRUTH: HOOKAH LOUNGES CATER TO YOUNG PEOPLE
• Nearly 1 in every 13 (7.8%) high school
students in the U.S. had used hookah during the
previous year according to 2019 NYTS data
• A 2017 study published in the New England J. of
Medicine found that 13% of 15–17-year-olds and
44.4% of 18–24-year-olds had ever used
hookah/waterpipe tobacco
• In California, 9.2 % of high school students
reported ever using hookah
• 30.8% of e-cigarette retailers near CA college
campuses (1-4 miles) sold hookah
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Photo Credit: Stanford UniversityTRUTH: HOOKAH LOUNGES STEREOTYPE AND
SEXUALIZE MIDDLE EASTERN CULTURE
• Hookah lounges often rely on overblown
stereotypes of “middle eastern” or “exotic” cultures
• Hookah lounges often use overtly sexualized
images in their advertisements
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Photo Credits: Stanford UniversityTRUTH: HOOKAH TARGETS SAME COMMUNITIES AS
OTHER COMMERCIAL TOBACCO
• 2019 NYTS data shows that high school students who
identify as either “Hispanic” or “Black, non-Hispanic”
currently use hookah at rates of 6.4 percent and 4
percent, while high school students identify as “White,
non-Hispanic” currently use hookah at a rate of 2.5
percent
• California study found that those identifying as Latinx
comprised 40 percent of the population that use hookah
• NATS found higher prevalence of hookah use among
Black Latinx community compared to non-Hispanic white
counterparts
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Source: Lincoln Mondy, Black Lives, Black Lungs (2017)TRUTH: HOOKAH IS PROHIBITED IN PARTS OF MIDDLE
EAST AND INDIA
• Hookah is prohibited in public places, including restaurants and cafes in Iran, three Indian
states, and two Saudi Arabian cities
• In order to limit spread of COVID-19, Saudi Arabia, UAE, Qatar, and Kuwait have all banned
hookah use, as well as Indian state of Delhi
1/15/2021 19MYTH: HOOKAH IS ONLY USED BY RESPONSIBLE
ADULTS
- Hookahs are 3 feet tall and cannot be easily
concealed in your pocket or backpack like vape.
- Hookahs take 25 – 30 minutes to set up and need
hot coals, therefore it cannot be smoked during
recess in the bathroom at school.
- Hookah’s cost over $200 for all the parts and
accessories, making it out of reach for most kids.
- Hookahs are not being confiscated in schools
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Photo Credit: Fumari 2020TRUTH: KIDS USE HOOKAH & INDUSTRY TARGETS KIDS
1/15/2021 21MYTH: ALL SHISHA IS FLAVORED
• A flavor ban is a de facto shisha ban
1/15/2021 22TRUTH: SOME SHISHA IS “UNFLAVORED”
• While not popular within the
nightclub crowd, “traditional”
hookah has tobacco and
molasses (or honeyed =
mu’assel)
1/15/2021 23TRUTH: SOME SHISHA IS “UNFLAVORED”
1/15/2021 24
Credit: Truth Initiative 2018MYTH: HERBAL SHISHA IS MUCH SAFER THAN
SHISHA THAT CONTAINS TOBACCO
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Photo credit: https://pipesarsenal.com/fantasia-herbal-shisha-
50g-10pk-apple-z407apl/TRUTH: EVEN HERBAL SHISHA IMPACTS HEALTH
• There is great variability in the composition of herbal shisha
which can contain even more toxic trace metals and
carcinogens than found in cigarettes
• The mainstream and sidestream smoke from the burning
of herbal shisha contains carcinogens equivalent to or
greater than that of tobacco containing products
1/15/2021 26TRUTH: EVEN HERBAL SHISHA IMPACTS HEALTH
• One study found that among lounges that claimed to only
use herbal shisha, nicotine was still detectable in the air
• In cafes or lounges where herbal shisha is smoked, air
quality is potentially hazardous as it may contain
significant amounts of fine particulate matter
• When heated, the flavor additives in shisha can result in a
higher concentration of harmful chemicals in smoke than
unflavored shisha
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Credit: Johns Hopkins UniversityMYTH: HOOKAH USE DOESN’T LEAD TO OTHER
TOBACCO PRODUCT USE
1/15/2021 28TRUTH: HOOKAH USE CAN LEAD TO CIGARETTE USE
• 2014 Dartmouth study and 2015
study published in JAMA Pediatrics
found that young people who use
hookah are twice as likely to pick
up a cigarette habit than those who
don’t
1/15/2021 29TRUTH: HOOKAH USE IS CORRELATED WITH
OTHER SUBSTANCE USE
1/15/2021 30WHY A FLAVOR BAN?
• It works!
• New York City
– Youth had 37% lower odds of ever trying flavored tobacco products
– 28% lower odds of ever using any type of tobacco
• Providence, Rhode Island
– Use of any tobacco product for high schoolers dropped from 22% to 12%
– E-cigarette use declined from 13.3% to 6.6%
1/15/2021 31SB-793
• Bans sale of flavored tobacco products
• Covers “tobacco retailers,” their agents and
employees
– Selling tobacco products from a “retail location” or
vending machine
• “Characterizing flavor” includes mint and menthol!
– Hard fought win for public health and equity
1/15/2021 32SB-793
HOOKAH EXEMPTION
• Exemption added in Senate
• Hookah and shisha exempt if:
– Licensed to sell tobacco products
– No one under 21 allowed
– Comply with rules for tobacco retailer
• Bill still covers e-hookahs
1/15/2021 33• Under stipulation, law did not take effect
on Jan 1 pending outcome of signature
verification
1/15/2021 34NO PREEMPTION!
• Explicitly does not preempt local action going
beyond state law
– Sets a minimum standard
• Local governments can pass laws that close the
loopholes in the state bill
1/15/2021 35CHALLENGES: ENFORCEMENT
• Many hookah lounges advertise
themselves as hookah-cafés and serve
food and alcohol
1/15/2021 36CHALLENGES: ENFORCEMENT
• Hookah lounges operating after bars close as
after-hours clubs already attract increased
law enforcement presence
1/15/2021 37CA STATE WORKPLACE LAW
• Exceptions to smoke-free workplace law
– “Private smoker’s lounge” = dedicated to the
use of tobacco products
– “Retail tobacco shops” = main purpose is
selling tobacco products
• CA AG Opinion
• CA DPH Guidance – no food/ beverages
• But enforcement may be challenging
– Courts not bound by these opinions
1/15/2021 38OUR MODEL ORDINANCE
Best Practices
Jurisdiction-wide ban
Menthol flavors prohibited
All tobacco products
No retailer exemptions
– hookah or tobacco bars
– retail tobacco stores
– adult-only shops
1/15/2021 39HOOKAH OPTIONS
FLAVOR BAN
• Ban all flavors for all products, including hookah
• Many have comprehensive flavor bans (all products, all flavors, all places), including:
• Alameda • Marin Cty
• Berkeley • Oxnard
• Carson • Palo Alto
• Contra Costa Cty • Sacramento
• Cupertino • San Francisco
• Davis • Santa Cruz Cty
• Delano • Santa Maria
• Fremont • Watsonville
• Los Angeles Cty • Yolo Cty
• Livermore
1/15/2021 40HOOKAH OPTIONS
COVER ALL SALES
• SB793’s coverage of online sales is unclear:
– “retail location” as “a building from which tobacco products are sold at retail.”
• Also, shisha and hookah paraphernalia can currently be sold online without ID
• Options:
– Cover all online sales, like San Francisco
– Enforce minimum 21 age verification to ensure no illegal underage sales
• Chicago and New York take this approach
1/15/2021 41HOOKAH OPTIONS
AGE REQUIREMENTS
• Can mirror the SB793 requirements and restrict entry into hookah bars and smokers’
lounges for anyone under 21
• California does not have a minimum age of sale for non-nicotine, herbal shisha
– Can extend a minimum 21 legal sales age for these products
– Still contains carbon monoxide and other toxins that cause cancer
1/15/2021 42HOOKAH OPTIONS
MASSACHUSETTS APPROACH
• Require only incidental sales of food or alcohol:
– “an establishment that: (i) exclusively occupies an enclosed indoor space and is primarily
engaged in the retail sale of tobacco products as defined in section 6 for consumption by
customers on the premises; (ii) derives revenue from the sale of food, alcohol or other
beverages that is incidental to the sale of a tobacco product and prohibits entry to a person
under 21 years of age; (iii) prohibits a food or beverage not sold directly by the
establishment from being consumed on the premises; (iv) maintains a valid permit for the
retail sale of a tobacco product” (Mass. Gen. Laws c.270 § 22(a))
1/15/2021 43HOOKAH OPTIONS
CHICAGO APPROACH
• Exclude businesses with food or liquor licenses:
– “‘Retail tobacco store’ means a retail establishment that derives more than 80% of its gross
revenue from the sale of loose tobacco, cigarettes, cigarillos, cigars, pipes, other smoking
devices and accessories, hookahs and related products, and/or electronic cigarettes and
related products, and in which the sale of other products is merely incidental. ‘Retail
tobacco store’ does not include a tobacco department or section of a larger commercial
establishment or any establishment with any type of liquor, food, or restaurant license.”
Chicago, Ill., Code § 7-32-010 (2019).
1/15/2021 44HOOKAH OPTIONS
OAKLAND APPROACH
• Prohibit food sales outright:
– “This section does not apply to the sale or offer for sale of Flavored Tobacco Products by a
‘Tobacco Store.’” “Tobacco Store” is a retail business that primarily sells tobacco products;
generates more than 60 percent of its gross revenues annually from the sale of tobacco
products and tobacco paraphernalia; does not permit any person under 18 years of age to
be present or enter the premises at any time, unless accompanied by the person’s parent
or legal guardian; and does not sell alcoholic beverages or food for consumption on the
premises.” Oakland, Cal., Code 5.91 (2019).
• Palo Alto, CA also takes a similar approach with its exemption
1/15/2021 45LITIGATION RISK
Neighborhood Market Assn. v. San Diego Cty.
• San Diego Cty’s ban has a hookah exemption
• NMA calls it an “arbitrary exception”
• Argues it creates a “tobacco product standard”
– Points to San Diego definition of shisha, which lists
“molasses, honey, fruit pulp, or dried fruits” as traditional
ingredients
• Claim may not succeed, but shows litigation risk
1/15/2021 46LOCAL ORDINANCE TIPS
• Stress public health message
– There is no safe form of tobacco
– All flavored products make it easier to start, harder to quit, attract youth
• Exemptions entrench inequities
• Local action can help build support for state referendum
1/15/2021 47KNOW YOUR RESOURCES
1/15/2021 48CONTACT US
651.290.7506
publichealthlawcenter@mitchellhamline.edu
www.publichealthlawcenter.org/caltobacco
@phealthlawctr
facebook.com/publichealthlawcenter
1/15/2021 49You can also read
